Navy Training: Safety Has Been Improved, but More Still Needs to Be Done
NSIAD-89-119
Published: Mar 07, 1989. Publicly Released: Mar 07, 1989.
Skip to Highlights
Highlights
Pursuant to a congressional request, GAO investigated the circumstances surrounding the death of a Navy enlistee during swimming training, focusing on: (1) how and why the incident occurred; (2) the Navy's actions to prevent a recurrence; (3) the adequacy of an investigation into the enlistee's death; and (4) whether safety problems have contributed to other Navy training deaths since January 1986.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status Sort descending |
|---|---|---|
| Naval Education and Training Command | The Chief of Naval Education and Training should ensure that the selection process for instructors of high-risk courses includes an assessment of their suitability for that kind of environment and that instructor training for those courses includes preparation on how to deal with students in a high-stress or high-risk environment. |
Policies have been revised to require review of personnel and medical records. If any questions emerge from this review, the commander can request formal medical or psychological screening. The Navy is also working on developing additional screening devices.
|
| Naval Education and Training Command | The Chief of Naval Education and Training should ensure that the student selection process also includes some psychological screening of their suitability for high-risk occupations. |
With improved safeguards for DOR and TTO and increased instructor training and screening, the Navy believes student screening can safely occur during training.
|
| Naval Education and Training Command | The Chief of Naval Education and Training should ensure that course safety review teams include personnel with safety expertise. |
CNET safety review teams now contain members with safety expertise.
|
| Naval Education and Training Command | The Chief of Naval Education and Training should ensure that controls on student status changes are sufficient to provide supervisors with a clear indication of what status changes have been made. |
Policies have been revised to task local commanders with responsibility for ensuring accurate knowledge of student status changes. Safety reviews will monitor for compliance.
|
| Department of the Navy | The Secretary of the Navy should require that investigator notes be retained with the Judge Advocate General Manual investigation file. |
The Navy disagreed with the recommendation to retain investigator notes and intends to take no action. This issue will be re-examined by GAO in a current assignment on Department of Defense Training Safety.
|
| Department of the Navy | The Secretary of the Navy should direct that any legal opinions that affect the course of an investigation be documented and made a part of the case file. |
Policy has been revised to require documentation of legal opinions in the case file.
|
| Naval Education and Training Command | The Chief of Naval Education and Training should eliminate the negative sanctions imposed on those who drop out of voluntary training programs because of safety concerns. |
New Navy policy prohibits negative sanctions and regular safety reviews will check on implementation.
|
| Department of the Navy | The Secretary of the Navy should review the regulations and procedures applicable to death investigations to clarify under what circumstances investigations should be performed, who should perform them, how investigative authorities are informed that death has occurred, and how the findings of death investigations should be disseminated. |
The Navy has reviewed its regulations and policies and clarified the circumstances under which investigations are to be made, who should perform them, and how their results should be disseminated.
|
| Naval Education and Training Command | The Chief of Naval Education and Training should clarify the aviation anti-submarine warfare (ASW) operator enlistment contract to include a better description of the kind of training that is required. |
The ASW contract has been revised to provide a better description of the type of training.
|
| Naval Education and Training Command | The Chief of Naval Education and Training should clarify the way the drop-on-request (DOR) and training-time-out (TTO) policies are communicated to the students and staff and how students are to signal that they are invoking the policies. |
All CNET high-risk courses now have incorporated DOR and TTO policies into their programs with standardized signalling.
|
| Naval Education and Training Command | The Chief of Naval Education and Training should ensure that schools comply with requirements to submit accident or injury reports and safety officers perform independent safety investigations of those incidents. |
Commanders are now required to investigate and report all training-related injuries. Since September 1989, each high-risk course was required to be assigned a safety officer to conduct independent investigations.
|
| Naval Education and Training Command | The Chief of Naval Education and Training should ensure that training course model managers receive information on attrition and accidents or injuries. |
Policies have been revised to require that attrition and accident/injury information goes to course curriculum model managers.
|
| Naval Education and Training Command | The Chief of Naval Education and Training should improve the student critique system to ensure that information is also gathered from students who do not complete training courses and that the student evaluation forms are redesigned to provide useful assessments. |
Student critique system policies have been revised to require critiques from attrited students also. Compliance will be monitored in high-risk course reviews.
|
Full Report
Office of Public Affairs
Topics
Accident preventionEnlisted personnelInternal controlsInvestigations by federal agenciesNaval personnelNaval trainingOccupational health standardsOccupational safetyPersonnel managementSafety standards